Pain management

Learning objectives

At the end of the workshop you will be able to:

• Consider the important principles of pain and pain management

• Use validated tools to assist in assessing patients pain

• Outline strategies to manage pain with your patients

• Discuss pain medicines with your patients

What is pain?

• A message to the brain, pain is a ’whole body’ experience and involves both the mind and the body

• Usually a protective mechanism to warn us to be more careful of our bodies

• It hurts and may cause suffering or distress

• Different for different people: it is whatever the person says hurts

Types of pain

• Acute pain can be important for the body to tell the brain that there is something wrong and help to avoid harm.

• Chronic pain is pain that goes on for a long time. It needs regular assessment and a different approach to treatment.

Chronic pain impacts on the whole person and their community

Ask your patients about any changes that have happened in their lives since their ongoing pain started.

For example:

• How are you sleeping?

• Are you feeling worried or sad?

• Are you still visiting friends or relatives?

• Are you eating well?

Things to talk about:• How pain is affecting their life

• Where the pain is, how bad the pain is

• How long they have had the pain

• What medicines they are taking for the pain (and any other conditions)

• How the pain has affected them and their family

• If they have any other problems or worries

• Make sure people understand that it may not be possible to be pain-free at all times

• Anticipation of pain

How do we assess painAsk the patient:

• To describe their pain

• Rate their pain (use the faces scale based on how they perform everyday activities)

• What made the pain worse or better

Observe the person’s body language (how freely do they move).

Talk with the person about how they feel, and how it affects their everyday life

Talk with their family when appropriate

Make sure people understand that it may not be possible to be pain-free at all times

REMINDER:

Use the same pain assessment tool to keep a detailed record of the patients’ pain changes in the clinic notes.

Managing chronic pain

Treatment goals:

• To improve the level of activity

• To modify thoughts about pain and suffering

• To promote self-management

• To relieve pain to a tolerable level

Managing chronic pain

Tips on helping people to exercise

• Educate patients that there is a difference between ‘hurt’ and ‘harm’ when you have chronic pain. Avoiding physical activity can make their pain seem worse over time.

• Encourage patients to talk to their family and friends and not isolate themselves. Also get a family member or friend involved as their ‘exercise buddy’.

• You may wish to suggest some exercises to try e.g. walking, swimming, gentle stretching exercises. Remember to start slow with exercise as they may feel some discomfort initially, especially if they have been inactive for a long time.

Medicines

Key points:

• Use a step-wise approach to introduce pain medicines (analgesics)

• Prescribe regular doses of analgesics

• Plan a trial period with clear and specific instructions

• Review the effects on regular basis eg may need more frequent review for new medicines or when dose changes

Analgesics – Non-opioid analgesics

AMH 2010, CARPA 5th edition

Nonsteroidal anti-inflammatory drugs (NSAID)

Generic names and how given

Other NSAIDS

Diclofenac Indomethacin Ketoprofen Ketorolac Mefenamic acid Naproxen Piroxicam Tiaprofenic acid

Cox-2 Inhibitors: Celecoxib Meloxicam Parecoxib

What it is used for

Mild to moderate pain and feverReduces swelling and inflammation in arthritis , period pain, sprains and injuries or attacks of goutRenal colicSuppositories are used when the patient is vomiting .They can still cause stomach pain when used for long period sGels can be used as a rubbing medicineCan be used with other medicines

How it works

Prostaglandins in the body cause redness, swelling and pain at the site of injury. NSAIDs stop the body making prostaglandins

Adverse effects

AMH 2010, CARPA 5th edition

Short-acting and long-acting opioids

Short-acting opioids

codeine

Tramadol

hydromorphone

Immediate-release morphine

Immediate-release oxycodone

Immediate-release tramadol

Long-acting opioids

Modifies release tramadol

Methadone

Modified-release hydromorphone

Modified-release morphine

Modified-release oxycodone

Transdermal buprenorphine

Transdermal fentanyl

Opioid analgesics – Combination analgesics

Generic names and how given

PARACETAMOL + Codeine 30 mg(Panadeine Forte ®, Codalgin Forte ®)

What it is used for

Moderate to strong pain reliefCan be used in combination with other pain relief medicines

How it works

Two different medicines work together (but in different ways) in the brain and nerve ending to reduce pain

Adverse effects

•Drink lots of water to prevent constipation Laxatives may be needed

• Return to the clinic if need to Use for more than a short time

•If you take more than 8 tab lets a day containing paracetamol you can damage your liver (make sure there is no paracetamol in your other medicines)

Opioid analgesics - Morphine

AMH 2010, CARPA 5th edition

Opioid analgesics - Tramadol

Generic namesand how given

TRAMADOL

What it is used for

Moderate to severe painSlow release formulations are used for chronic pain

How it works

Adverse effects

Drug interactions (do not take with) Warfarin SSRI Venlafaxine Carbamazepine St John’s Wort

AMH 2010, CARPA 5th edition

Take home messages

When you see a person who has pain:

• Perform a thorough history and physical examination to

determine if  referral is necessary

• Discuss options for managing pain with the person

• Recommend medicine only as part of an agreed pain

management plan

Resources

• Australian Pain Management Association’s Pain Link Helpline (1300 340 357)

• Australia’s National Phone Information and Support line

(1800 218 921) Provide support for patients, their carers and health professionals.

• Chronic pain Australia – www.chronicpainaustralia.org

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